Sandra Wartski, PsyD, CEDS
The severe stigma and bias associated with larger bodies is well established in eating disorders literature,1, 2 and we are aware that the many negative consequences of such attitudes are far reaching. Eating disorder professionals are especially aware of this prejudice, for it is interwoven in our work with recovering individuals of any size. We can often feel we are waging an uphill battle with our clients as we attempt to shift attitudes about body acceptance. However, we also know this bias goes far beyond our clients—this rampant societal movement affects everyone negatively.
We may be saddened but also not completely shocked when we hear about a study of children who say they would rather lose an arm than be fat or hear of a news headline recounting a tragic ending for someone bullied due to their weight.3 Clinicians know firsthand how stigmatization and shame lead to greater – not fewer – difficulties with eating, self-esteem, mood, and overall mental health.4,5 Recently I was further discouraged when I heard about a new report on the Implicit Association Test results reviewing positive changes in sexuality and racial biases. Unfortunately, there were no changes in body weight bias.
New Findings on Body Bias
The Implicit Association Test (IAT) is described as a way to measure “attitudes and beliefs that people may be unwilling or unable to report.” Many individuals consider themselves unbiased and non-prejudiced, but all of us are believed to have underlying implicit attitudes about which we are unaware. Project Implicit® was founded in 1998 by three scientists, Dr. Tony Greenwald, Dr. Mahzarin Banaji, and Dr. Brian Nosek. Project Implicit Health (formerly Project Implicit Mental Health) was launched in 2011 and is led by Drs. Bethany Teachman and Matt Nock. The mission of Project Implicit is to educate the public about bias, and to provide a “virtual laboratory” for collecting data on the internet. Project Implicit is a way for scientists to “produce high-impact research that forms the basis of our scientific knowledge about bias and disparities.”6 The data collection has gone on continuously on the internet since 2007; since that time, more than 40 million tests have been taken, creating a much more expanded set of data than the researchers had ever expected.
One of the scientists who founded Project Implicit is Mahzarin Banaji, PhD, professor of social ethics in the Department of Psychology at Harvard University, and a pioneer in the study of implicit bias. She is the author, with Anthony Greenwald, PhD, of the 2013 book Blindspot: Hidden Biases of Good People.7
Dr. Banaji was recently interviewed on the podcast of the American Psychological Association, “Speaking of Psychology.” Episode 199 is entitled “Can we unlearn implicit biases?” and covers a wide range of interesting findings, but her briefly mentioned reference to larger body bias felt especially relevant to eating disorder professionals.8
Dr. Banaji shared results of the analysis of six groups, looking at anti-gay bias, racial bias, skin tone bias, age bias, disability, and body weight bias (bias against people who are overweight). Various interesting and surprising findings were revealed, and researchers are studying why some beliefs change quicker than others. The biggest shift was in the finding that anti-gay bias has dropped off by 64% between 2007 and 2020, a huge decrease. Race and skin tone have been reduced by about 25% during that same period.
Three biases that have not shifted much at all are: anti-elderly bias is slightly but not significantly lower, while disability and body weight bias remain completely unchanged. Dr. Banaji noted that body weight bias seems so stable that “We think these biases are going to be around. If they move at this rate, we’re not going to see change for 200 years. That’s our prediction.” As exciting as it is that some important biases have decreased, and are starting to shift in important ways, especially as implicit biases have often been considered to be less moveable, the continued bias against larger bodies is discouraging.
Things That Can Further Hurt
A number of factors make this process of shifting attitudes about body weight difficult, and most of us recognize that the impact of sociocultural factors is huge. News about a “great new diet” or public commentary about someone’s body (most commonly highlighting weight loss or criticizing weight gain) reinforces the notion of things being wrong or bad among people of certain body sizes or shapes. We all know there are certainly no shortages of this sort of over-focus, and with summertime being strategically timed to have diet-body-loathing-change-focus, the over-focus will basically be maintained all year long, especially with the extensively increased exposure now available with the internet and social media. Diet culture exalts thinness, vilifies bigger bodies, and normalizes many disordered eating behaviors. We know that even if someone does not progress to a diagnosis of an eating disorder, our fat-phobic society continues to show significant oppression, prejudice, and discrimination.
In January 2023, the American Academy of Pediatrics (AAP) published “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescent Obesity.” It is an example of a factor that has the potential to negatively impact any small steps of changes that have begun to happen with more of the HAES (Health at Every Size®) and weight-neutral movement. The Guideline urges pediatricians to speak with children and their families about dieting, medications and even weight loss surgery. First and foremost, the HAES principles promote safe and equitable access to healthcare for people regardless of size, health status, and healthy goals. Fortunately, various groups have expressed serious concern about the current recommendations. Petitions are being signed in opposition to the guidelines, and EDC meetings with the AAP have begun to lead to positive changes.
Things That Can Help
Attitudes can change, and beliefs can shift. Indeed, it would be hard to maintain hopefulness and optimism about eating disorders treatment if we did not ultimately consider change to be viable. However, unlearning bias is more difficult than we often think. Clinicians are actually in this wide dialectical gap: we know that humans often resist and are uncomfortable with change, yet our life’s work is basically focused, at least in part, on helping individuals change.
Taking Small Steps
Although we sometimes believe people have to shift their beliefs before they can shift their behaviors, science actually supports the notion that taking small behavioral steps can precede a belief change. Arguing oneself or others out of a bias tends not to work, and most people actually end up holding on even more stubbornly to some of those beliefs – as many clinicians well know. We also know there is so much psychoeducation to cover in eating disorders work, but education alone has rarely allowed someone to make sustainable changes. So, those mini-strides of behavioral change, such as leaving the house even if someone doesn’t feel presentable or engaging in compassionate self-talk even without believing it, can actually be important starts.
Tiny steps count. The focus on tiny steps of change cannot be oversold. Many clients will say, “There is no way I could love my body,” but sometimes they can buy into a smaller intention, such as attempting to focus more on honoring or trusting a body signal (for thirst, urination, or sleep, for example). Similarly, we cannot expect that society will be able to make immediate leaps to more of a weight-inclusive culture, but society might begin to consider how health is more accurately measured in behaviors than by a specific weight or size. Even one degree of change shifts the trajectory significantly.
Finding ways to create cognitive dissonance can also be helpful. Leon Festinger, credited with developing the theory of cognitive dissonance in the 1950s and 1960s, noted that when we are confronted with two seemingly dissimilar ideas, we must change one or the other.9 This discomfort in inconsistent cognitions turns out to actually be motivating. Going back to some of the IAT results, in attempting to uncover why some biases change faster (such as the rapidly decreasing anti-gay bias), scientists have proposed that when sexuality became more personal and more people began “coming out” to loved ones, the sexuality bias was able to be shifted more quickly. As people “came out,” families and friends were forced to confront their own cognitive dissonance. Similarly, we can find more ways for people of all sizes to be revered for who they are and for what they do (as scientists, teachers, healthcare professionals, good parents, helpful colleagues, and kind human beings), in order to expand the currently more limited notion based only on weight.
Hollywood is also credited with assisting in shifting the anti-gay bias revealed in the IAT results much more quickly than any of the other unchanging biases. As Dr. Banaji explained, “They made movies and they made TV shows, not just ordinary ones, but ones in which the gay character would be cooler and smarter and nicer than the straight people on the show. People watched those and came to see that this was being normalized.” Having more body types on TV and in movies would appear an important and worthwhile goal that might indeed begin to slowly but steadily shift the fat phobic mindset. Humans are adaptable, and revered role models can help in this evolution.
We also can come back to recognizing that bias is learned. Babies are not born with prejudices, but eventually are molded by families and societies in both explicit and implicit ways. While we want to assist in some unlearning of harmful notions for current citizens, we can also impact caregivers of the new generations to be more thoughtful about how body weight biases are passed along from the very start. Pushing past assumptions, making new norms, and challenging the status quo will be part of creating a more just and non-discriminatory world in many domains.
Looking to the Future
It may be a long time before we can really expect that weight-inclusive care and weight-neutral conversations will become the norm, but fortunately there are some small behavioral steps we can take to increase awareness and support slow shifts. We may still be at a more rudimentary point of attempting to prevent harm in medical treatment guidelines or reduce negative impact from some toxic social media trend, but hopefulness about reduction in other biases does provide some optimism about eventual positive prognosis in body weight bias as well.
As Lindo Bacon, of HAES (Health at Every Size), an activist and author, has so wisely noted, “The only way to solve the weight problem is to stop making weight a problem – to stop judging ourselves and others by our size. Weight is not an effective measure of attractiveness, moral character or health.”10
- Fruh SM, Nadglowski J, Hall HR, et al. 2016. Obesity stigma and bias. J Nurse Pract. 12:425.
- Puhl RM, Heuer CA. (2009). The stigma of obesity: a review and update. Obesity. 17:941.
- Solovay S. 2000. Tipping the scales of justice: Fighting weight based discrimination. Prometheus. SoundCloud.
- Flament MF, Henderson K, Buchholz A, et al. 2015. Weight status and DSM-5 diagnoses of eating disorders in adolescents from the community. J Am Acad Child Adolesc Psychiatry. 54:403.
- Puhl RM, Lessard LM. 2020. Weight stigma in youth: prevalence, consequences, and considerations for clinical practice. Curr Obes Rep. 9:402.
- Project Implicit website: https://implicit.harvard.edu/implicit/aboutus.html
- Banaji M, Greenwald A. 2001. Blindspot: Hidden Biases of Good People. Delacorte Press, New York, NY.
- Banaji M. 2022. Speaking of psychology. Can we unlearn implicit biases?
podcast on implicit bias:
- Festinger L. 1962. A Theory of Cognitive Dissonance. Stanford University Press, Stanford, CA.
- Bacon L. 2010. Health At Every Size: The Surprising Truth About Your Weight. BenBella Books, Dallas, TX.